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BackgroundIn recent years, the use of Indocyanine Green (ICG) fluorescence-guided surgery during open and laparoscopic procedures has exponentially expanded across various clinical settings. The European Association of Endoscopic Surgery (EAES) initiated a consensus development conference on this topic with the aim of creating evidence-based statements and recommendations for the surgical community.MethodsAn expert panel of surgeons has been selected and invited to participate to this project. Systematic reviews of the PubMed, Embase and Cochrane libraries were performed to identify evidence on potential benefits of ICG fluorescence-guided surgery on clinical practice and patient outcomes. Statements and recommendations were prepared and unanimously agreed by the panel; they were then submitted to all EAES members through a two-rounds online survey and results presented at the EAES annual congress, Barcelona, November 2021.ResultsA total of 18,273 abstracts were screened with 117 articles included. 22 statements and 16 recommendations were generated and approved. In some areas, such as the use of ICG fluorescence-guided surgery during laparoscopic cholecystectomy, the perfusion assessment in colorectal surgery and the search for the sentinel lymph nodes in gynaecological malignancies, the large number of evidences in literature has allowed us to strongly recommend the use of ICG for a better anatomical definition and a reduction in post-operative complications.ConclusionsOverall, from the systematic literature review performed by the experts panel and the survey extended to all EAES members, ICG fluorescence-guided surgery could be considered a safe and effective technology. Future robust clinical research is required to specifically validate multiple organ-specific applications and the potential benefits of this technique on clinical outcomes.

IntroductionThere has been a constant increase in the number of published surgical videos with preference for open-access sources, but the proportion of videos undergoing peer-review prior to publication has markedly decreased, raising questions over quality of the educational content presented. The aim of this study was the development and validation of a standard framework for the appraisal of surgical videos submitted for presentation and publication, the LAParoscopic surgery Video Educational GuidelineS (LAP-VEGaS) video assessment tool.MethodsAn international committee identified items for inclusion in the LAP-VEGaS video assessment tool and finalised the marking score utilising Delphi methodology. The tool was finally validated by anonymous evaluation of selected videos by a group of validators not involved in the tool development.Results9 items were included in the LAP-VEGaS video assessment tool, with every item scoring from 0 (item not presented in the video) to 2 (item extensively presented in the video), with a total marking score ranging from 0 to 18. The LAP-VEGaS video assessment tool resulted highly accurate in identifying and selecting videos for acceptance for conference presentation and publication, with high level of internal consistency and generalisability.ConclusionsWe propose that peer review in adherence to the LAP-VEGaS video assessment tool could enhance the overall quality of published video outputs.Graphic Abstract

BackgroundSince the introduction of laparoscopic surgery, it has become more popular with many advantages over open surgery including faster recovery, shorter hospital stays, and decreased tissue trauma. Despite its benefits, laparoscopic surgery can result in its own unique complications, such as the formation of a trocar site hernia (TSH), which have been reported in approximately 0–1.0% of laparoscopic cases when using non-bladed trocars.MethodsA literature review was performed from June 1990 to June 2019. PubMed was searched using the keywords “laparoscopic surgery,” “trocar site hernia,” and “port site hernia.” Only articles in English were identified but not limited to the USA.ResultsThe total number of patients in all articles was 18,533 with a mean follow-up period of 22.50 ± 1.76 months. The overall trocar site hernia rate was 0.104%. When comparing open vs. closed ports, there was no significant difference in the hernia incidence rate for 5-mm and 10-mm ports. When comparing bladed versus non-bladed trocars left open, there was a statistically significant difference with lower hernia incidence rates for non-bladed trocars over bladed trocars for 5-mm, 10-mm, and 12-mm ports. And when comparing trocar location from midline versus off-midline, there was a statistically significant higher TSH incidence in midline trocar locations.ConclusionResults suggest that TSH rate is lower when using non-bladed trocars for any size of trocar. When comparing whether fascial closure had an effect, the 5-mm and 10-mm ports had no difference in incidence rates and leaving the fascia open can reduce operative time, risk of needlestick injuries, and overall procedural cost. In addition, trocars at midline locations resulted in higher TSH incidence rates. Future research is still needed to assess for other factors that may influence hernia formation and how it can be minimized.

Purpose To compare single-incision laparoscopic surgery (SILS) and multiport laparoscopic surgery (MLS) for colorectal cancer in terms of short- and long-term outcomes. Methods A systematic literature search was performed in PubMed, Web of Science, and Embase. Randomized controlled trials (RCTs) and propensity-score matched (PSM) studies comparing SILS and MLS for colorectal cancer were enrolled. Outcomes of interests included intraoperative, postoperative, pathological, and survival outcomes. Results Sixteen studies (6 RCTs and 10 PSM studies) published between 2012 and 2020 with a total of 2425 patients were enrolled. Compared with MLS, SILS was associated with less postoperative pain at postoperative day (POD) 1 ( P = 0.02, MWD = −0.73, 95%CI: −1.37, −0.09) and POD2 ( P < 0.001, MWD= −1.10, 95%CI: −1.45, −0.74) and shorter length of total incision length ( P < 0.001, MWD = −3.31, 95%CI: −3.95, −2.67). No differences were observed in terms of operative time, blood loss, intraoperative and postoperative complications, incision hernia, and pathological or survival outcomes between SILS and MLS. Subgroup analysis for right-sided colon cancer, sigmoid colon cancer, and rectosigmoid colon cancer showed that the SILS group was only associated with less postoperative pain and shorter total incision length. The surgical and pathological outcomes were comparable between SILS and MLS. Conclusions SILS is a beneficial alternative to MLS in select colorectal cancer patients, especially for right-sided colon cancer, sigmoid colon cancer, and rectosigmoid cancer, with better cosmetic effects and less postoperative pain. Simultaneously, SILS does not compromise intraoperative and postoperative complications, surgical quality, or long-term outcomes.

Handbook of Laparoscopy Instruments covers the essential components of laparoscopic instruments and technology. It presents accessible information covering key topics on the subject: Ø Basic and specialized laparoscopic instruments Ø Image production Ø Pneumoperitoneum maintenance Ø Ergonomics Ø Sterilization procedures Ø Optical devices Ø Operation theatre layout and setup Ø Operative hand instruments Ø Robotic Surgery This book is an indispensable resource recommended for students and surgical residents who need an understanding of instruments and procedures in laparoscopic surgery. It is also intended to help medical professionals who want to start laparoscopy units in their clinics.

BackgroundThe repetitive and forceful motions used by operating surgeons increase the risk of developing musculoskeletal disorders. Most ergonomists consider the surgical environment to be incredibly harsh for its workers. Traditional Laparoscopic Surgery (TLS) in particular has a number of physical and mental challenges associated with it, and while Robotic-Assisted Laparoscopic Surgery (RALS) provides several features that improve upon TLS, some surgeons have still reported musculoskeletal symptoms they attribute to RALS. In this paper, we endeavored to systematically review muscle activation for both TLS and RALS, to compare the modalities and present the results as a meta-analysis.MethodsA literature search was conducted using Pubmed, Embase, and Cochrane databases in November 2018 with the following inclusion criteria: full text was available in English, the paper contained original data, EMG was one of the primary measurement techniques, and the paper included EMG data for both TLS and RALS. Results from studies were compared using standardized mean difference analysis.ResultsA total of 379 papers were found, and through screening ten were selected for inclusion. Sample populations ranged from 1 to 31 surgeons, and a variety of study designs and metrics were used between studies. The biceps were the only muscle group that consistently and significantly demonstrated lower muscle activation for RALS for all included studies.ConclusionsThe results may support the belief that RALS is ergonomically superior to TLS, shown through generally lower muscle activation scores. However, these results must be interpreted with caution due to the heterogeneity between the studies and multiple potential sources for bias within studies. This analysis would be strengthened with a higher number of homogenous, high-quality studies examining larger sample sizes.

Background Single-incision plus one-port laparoscopic surgery (SILS + 1) has been demonstrated to be minimally invasive while possessing better cosmesis and less pain compared with conventional laparoscopic surgery (CLS). However, SILS + 1 as an alternative to CLS for colorectal cancer is still controversial. Methods A total of 1071 patients who underwent curative laparoscopic surgery for colon cancer between 2015 and 2018 were included. Of these patients, 258 SILS + 1 cases and 516 CLS cases were analyzed using propensity score matching. The baseline characteristics, surgical outcomes, pathologic findings and recovery course, morbidity and mortality within postoperative 30 days and 3-year disease-free and overall survival were compared. Results Baseline characteristics were balanced between the groups. The mean operating time was significantly shorter in SILS + 1 group, with less estimated blood loss. Tumor size, tumor differentiation, number of harvested lymph nodes, resection margin and pathologic T, N, TNM stage was similar between the groups. There was no significant difference in overall perioperative complications. Uni- and multivariate analyses revealed that SILS + 1 was not a risk factor for complications. Postoperatively, SILS + 1 group showed faster recovery than CLS group in terms of ambulation, bowel function, oral intake and discharge. The 3-year disease-free survival rates of SILS + 1 and CLS groups were 90.1% and 87.3%(p = 0.59), respectively and the 3-year overall survival rates were 93.3% vs. 89.8%(p = 0.172). Discussion Our study revealed that SILS + 1 is safe, feasible, oncologically efficient, and may be considered as a surgical option for selected patients with colorectal cancer.

IntroductionTraditional laparoscopic surgery (TLS) has increasingly been associated with physical muscle strain for the operating surgeon. Robot-assisted laparoscopic surgery (RALS) may offer improved ergonomics. Ergonomics for the surgeon on these two platforms can be compared using surface electromyography (sEMG) to measure muscle activation, and the National Aeronautics and Space Administration Task Load Index (NTLX) survey to assess workload subjectively.MethodsSubjects were recruited and divided into groups according to level of expertise in traditional laparoscopic (TLS) and robot-assisted laparoscopic surgery (RALS): novice, traditional laparoscopic surgeons (TL surgeons), robot-assisted laparoscopic surgeons (RAL surgeons). Each subject performed three fundamentals of laparoscopic surgery (FLS) tasks in randomized order while sEMG data were obtained from bilateral biceps, triceps, deltoid, and trapezius muscles. After completing all tasks, subjects completed the NTLX survey. sEMG data normalized to the maximum voluntary contraction of each muscle (MVC%), and NTLX data were compared with unpaired t tests and considered significant with a p ≤ 0.05.ResultsMuscle activation was higher during TLS compared to RALS in most muscle groups for novices except for the trapezius muscles. Muscle activation scores were also higher for TLS among the groups with more experience, but the differences were less significant. NTLX scores were higher for the TLS platform compared to the RALS platform for novices.DiscussionTLS is associated with higher muscle activation in all muscle groups except for trapezius muscles, suggesting greater strain on the surgeon. Increased trapezius muscle activation on RALS has previously been documented and is likely due to the position of the eye piece. The differences seen in muscle activation diminish with increasing levels of expertise. Experience likely mitigates the ergonomic disadvantage of TLS. NTLX survey data suggest there are subjective benefits to RALS, namely in the perception of temporal demand. Further research to correlate NTLX data and sEMG measurements, and to investigate whether these metrics affect patient outcomes is warranted.

Purpose Scientific evidence supporting robotic-assisted laparoscopic surgery (RALS) for rectal cancer remains inconclusive because most previous reports were retrospective case series or case-control studies, with few reports focusing on long-term oncological outcomes with a large volume of patients. The aim of this study was to clarify the short- and long-term outcomes of a large number of consecutive patients with rectal cancer who underwent RALS in a single high-volume center. Methods The records of 551 consecutive patients who underwent RALS for rectal adenocarcinoma between December 2011 and March 2017 were examined to reveal the short-term outcomes. The oncological outcomes of the 204 patients who underwent surgery between December 2011 and March 2014 were evaluated. Results Most patients had tumors located in the lower or mid-rectum (86.0%). Only 7.6% of patients underwent neoadjuvant chemoradiotherapy. Lateral lymph node dissection was performed for 191 patients (34.7%). The median operative time was 257 min, median blood loss was 10 mL, and no transfusions were needed. No conversion to open surgery was necessary. Eighteen patients (3.3%) had Clavien-Dindo grade III postoperative complications. Six patients (1.1%) had positive resection margins. The mean follow-up duration of the 204 patients was 43.6 ± 9.8 (months). The 5-year cancer-specific survival rate for stage I/II/III/IV was 100%/100%/100%/not reached, respectively. The 5-year relapse-free survival rate for stage I/II/III/IV was 93.6%/75.0%/77.6%/ not reached, respectively. The rate of local recurrence was 0.5%. Conclusions Our results suggest that RALS is technically feasible for rectal cancer and has good short- and long-term outcomes.

BackgroundSingle-incision laparoscopic surgery (SILS) is a new technique that aims to minimize abdominal wall trauma and improve cosmesis. Concerns have been raised about the risk of trocar-site hernia following SILS. This study aims to assess the risk of trocar-site hernia following SILS compared to conventional laparoscopic surgery, and investigate whether current evidence is conclusive.MethodsWe performed a systematic search of MEDLINE, AMED, CINAHL, CENTRAL, and OpenGrey. We considered randomized clinical trials comparing the risk of trocar-site hernia with SILS and conventional laparoscopic surgery. Pooled odds ratios with 95% confidence intervals (CI) were calculated using the Mantel–Haenszel method. Trial sequential analysis using the Land and DeMets method was performed to assess the possibility of type I error and compute the information size.ResultsTwenty-three articles reporting a total of 2471 patients were included. SILS was associated with higher odds of trocar-site hernia compared to conventional laparoscopic surgery (odds ratio 2.37, 95% CI 1.25–4.50, p = 0.008). There was no evidence of between-study heterogeneity or small-study effects. The information size was calculated at 1687 patients and the Z-curve crossed the O’Brien–Fleming α-spending boundaries at 1137 patients, suggesting that the evidence of higher risk of trocar-site hernia with SILS compared to conventional laparoscopic surgery can be considered conclusive.ConclusionsSingle-incision laparoscopic procedures through the umbilicus are associated with a higher risk of trocar-site hernia compared to conventional laparoscopic surgery.